Pilot Debrief

GLASFLUGEL STANDARD LIBELLE near Wellington, CO — 2011-03-20

Final reportCEN11LA239
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Date
2011-03-20
Location
Wellington, CO, USA
Airport
4CO2
Aircraft
GLASFLUGEL STANDARD LIBELLE
Registration
N99AE
Category
Glider
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

The pilot's loss of glider control due to impairment or incapacitation caused by an episode of ventricular tachycardia.

NTSB narrative

The pilot was performing a local glider flight when the accident occurred. A witness saw the glider release from the towplane and saw the glider maneuver in steep bank turns as it descended during those turns. At one point, the glider was observed to enter a rapid "zoom" climb followed by a brief period of inverted flight before descending, wings level, about 60-degrees pitch down, into the ground. The glider was subsequently found in a ravine; the glider’s right wing had impacted an embankment and sustained substantial damage, and its dive brake was found extended. The left wing’s dive brake was found retracted. A postaccident examination of the wreckage revealed no preimpact anomalies that would have precluded normal operation. The pilot did not have a current medical certificate, but he was not required to have a medical certificate for glider operations. An autopsy indicated that the pilot's cause of death was multiple blunt force injuries and that cardiac disease may have been contributory. The pilot had a documented history of cardiac disease and had a pacemaker implant. The pacemaker was last checked about one month prior to the accident and it was operating normally at that time. A readout of the pilot’s pacemaker indicated that about the time of the accident the pilot experienced a ventricular tachycardia. The degree of the pilot’s injuries made it highly unlikely that he experienced the ventricular tachycardia as a result of the injuries, but that he experienced the condition prior to impact. The symptoms the pilot would have experienced as a result of the ventricular tachycardia likely impaired or incapacitated the pilot, and resulted in his loss of control of the glider. The toxicology results support the pilot’s use of prescription pain medications the evening before as indicated by his personal physician. None of these was in the therapeutic range at the time of the crash and were therefore unlikely to have contributed to the etiology of the event.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen not to perform steep bank turns during flight.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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